Skin Preps

Objectives State the rationale for performing skin preps. Identify different types of prepping agents and the indications and contraindications for each. Identify the prepping procedure for common types of surgery. List the components to be included in the documentation of skin preps.

Skin Layers Epidermis- made up of stratified squamous epithelium and constantly shedding. Dermis-Contains Collagen, elastin, hair follicles sweat glands, sebaceous glands, blood and lymph vessels and nerves.

Purpose Remove soil, debris, skin oils, lotions, transient microorganisms Decrease microorganism count on the skin Suppress the growth of microorganism population during surgery Reduce the hazard of microbial contamination by skin flora at the surgical site

Microorganisms E-coli Transient –organisms that are acquired through direct contact-attached loosely-removed by mechanical means Resident – organisms living below skin in hair follicles, sebaceous glands and sweat glands-reduced and neutralized by the antimicrobial agent Increased numbers of microorganisms in folds and wrinkles on skin The individual person is the primary source of nosocomial bacteria in the operative setting. Requires mechanical action & chemical agents to eliminate and prevent re-growth.

Principals of Skin Preps Skin is a major source of microbial contamination. Skin can never be sterilized. Transmission of microbes can cause an infection. Goals of surgical skin preps Remove soil and transient organisms Reduce resident microbial count Inhibit rapid rebound regrowth

Agents Soaps-a cleansing and emulsifying agent Detergents-preparations that are chemically different from soaps but are able to emulsify oils Antimicrobial agents-destroying or inhibiting the growth of microorganisms

Antimicrobial Agents Broad spectrum-kills wide range of organisms Persistent-maintenance of effectiveness over a long period of time Nonirritating Nontoxic Fast acting Always follow manufacturer’s recommendations for application.

Antimicrobial Agents Chlorhexidine Gluconate (CHG) ChloraPrep – GHG & Alcohol Hibiclens – CHG & Alcohol Iodophors (Betadine) Alcohol PCMX- (Technicare)

Chlorhexidine Gluconate Hibiclens™- 4% CHG & 4% alcohol ChloraPrep™ - 2% CHG & 70% alcohol Actions Disrupts cell membranes-kills fungus, bacteria & viruses Prevents regrowth for six hours Alcohol component acts as a degreaser Designed for topical skin application Cautious use above the neck Avoid eyes, ears, mucous membranes, nerve and meningeal tissues

Iodophors Invades cell walls and replaces with iodine Betadine : scrub & paint Invades cell walls and replaces with iodine Kills fungus, bacteria Limited duration of action Safe on mucous membranes Contraindications: Not for use on patients with allergies to iodine

PCMX-Technicare™ Contains 3.00% chloroxylenol Kills gram positive and gram negative bacteria Has good persistance Safe and effective for mucous membranes and around ears and eyes.

Alcohol 70% Isopropyl Alcohols are effective against most gram positive and negative bacteria, as well as most fungi and viruses. Does not have persistant action Use as a degreaser Used with other agents (such as Chlorhexidine to add persistence). Flammable

http://www.icsi.org/perioperative__protocol__36011/perioperative__protocol.html

Procedure Assessment Surgical site Integrity of skin Patient allergies to solutions

Procedure Preoperative cleansing Preoperative shower Preoperative wash of surgical site If patient obviously dirty and there is time (no threat of life or limb), take a scrub brush and do a pre wash of the surgical site.

Procedure Hair removal Outside of the operating room suite (optimal) As close to the time of surgery as possible Clippers (method of choice)

Abdominal Procedure (2 solutions) Abdominal skin prep – two solutions (betadine scrub & paint or Hibiclens & alcohol) Verify incision site. Explain procedure (if patient is awake). Determine area to be prepped. Expose only the area to be prepped.

Abdominal Procedure (2 solutions) Hold sponge by wings Abdominal prep Open prep set. Don sterile gloves and prepare the prep set. Place sterile towels on either side of the patient’s body. Solution 1: Use cotton-tipped applicators to swab out umbilicus. Hold sponge by wings or wrap gauze around fingertips - squeeze out excess solution.

Abdominal Procedure (2 solutions) Abdominal prep (solution 1 continued) Begin at the site of the incision and work outward. Discard used sponges - use new ones whenever returning to the incision site.

Blotting Abdominal Procedure (2 solutions) Blotting procedure- place towel on site blot area prep remove towel from far side, careful not to drag edges across prep area

Abdominal Procedure (2 solutions) Abdominal prep Solution 2 procedure: Begin at the incision site and use an outward circular motion to cover the scrubbed area. Repeat with a second sponge stick. Carefully remove runoff towels, discard prep materials. Allow to air dry.

ChloraPrep - Procedure Place ChloraPrep applicator and cotton tip applicators on sterile field. Hand to scrub or set up sterile table. Don Sterile gloves Place drip sheets. Pinch lever once until ampules break.

ChloraPrep - Procedure Swab umbilicus with cotton-tipped applicators. Press applicator against treatment area to evenly distribute solution in the sponge. Start at incision site in back and forth motion for 30 seconds. Continue to work outward to the peripheral area. Remove drip sheets - do not blot. Allow to air dry. Discard the applicator after single use.

VARIATIONS: VAGINAL PREP Choose appropriate agent. Place drape under patient’s buttocks. Prep thighs to pubis. Prep perineum from pubis to anus. Prep vaginal vault.

VARIATION: EXTREMITIES Start at incision site and move away, circumferentially. Shoulders and upper arms Knees and lower legs Hands and feet

PEDIATRIC CONSIDERATIONS Children have difficulty maintaining normothermia Caution when using warming measures

DOCUMENTATION Condition of the patient’s skin Hair removal Prepping agent(s) used Area of body prepped Person(s) performing the prep Development of any reaction